Tri-State Community Health Center, Inc
Organization Active NPI Federally Qualified Health Center (FQHC) · Cumberland, MD
NPI 1467401372 · NPPES record last updated May 6, 2010
Key facts
- NPI
- 1467401372
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- TRI-STATE COMMUNITY HEALTH CENTER, INC
- Practice address
- 12502 Willowbrook Road
Ste 550, 5TH FLR.
Cumberland, MD 21502-6393 - Phone
- (301) 723-3940
- Fax
- (301) 723-3941
- NPI assigned
- May 8, 2006
- Organization subpart
- No
Authorized official
- Name
- Sheila J Deshong IX
- Title
- Cheif Operating Officer
- Phone
- (301) 678-5187
Other NPIs on the same Medicare enrollment 2
Other NPIs with the same Medicare PAC ID 4
Corporate family (same tax ID) 6
Practitioners 19
-
Jorge Roberto Andrade, MD, MBA
-
Raymond E Banfer, MD
-
Stephanie Nicole Jarvis, CRNP
-
Daniel Chris Aukerman, M.D.
-
Teresa Ann Dumpe, CRNP
-
Terry Ellen Harvey, CRNP
-
Chelsea Shoaf, CRNP
-
Janell Sioma, CRNP
-
Jeannette Lois Sweitzer, CRNP
-
Danielle Ayers Destfino, CRNP, FNP-C
-
James W Freeman, MD
-
Ryan M. Hikes, MD
-
Stephen Anthony Hoffman, D.O.
-
Danielle L Houck, PA
-
Kelli Renee Oswald, CRNP
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in MD
Federally qualified health center certification: CCN 211849
- Legal name
- TRI-STATE COMMUNITY HEALTH CENTER INC
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Dec 7, 2005
- Last certification
- Dec 7, 2005
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Incorporated
- May 18, 1987 in MD
- Enrollment address
- 12502 Willowbrook Rd 550
Cumberland, MD 21502-6594
All disclosed owners & managing parties 13
| Name | Role | Since | Share |
|---|---|---|---|
| Carolyn Lee Clingerman |
Corporate Director |
Aug 6, 2018 | |
| Nancy Forlifer |
Corporate Director |
Jun 6, 2011 | |
| Katherine Ann Salesky |
Corporate Director |
Aug 6, 2018 | |
| Sheila J Deshong |
Corporate Officer |
Nov 1, 2005 | |
| W-2 Managing Employee |
Nov 1, 2005 | ||
| William Rocks |
Corporate Officer |
Sep 1, 2008 | |
| Tracy Lynn Salvagno |
Corporate Officer |
Dec 1, 2008 | 100% |
| Elen L Ott |
Corporate Director |
Oct 1, 2016 | |
| Audrey Lynn Morris |
Corporate Director |
Aug 14, 2014 | |
| Savin Ramani Pillai |
Corporate Director |
Apr 2, 2018 | |
| Cordelia J Carson |
Corporate Director |
Oct 7, 2013 | |
| Susan B Walter |
Corporate Officer |
Jul 1, 2011 | 100% |
| W-2 Managing Employee |
Jul 11, 2011 | 100% | |
| Satricia a Woodal |
W-2 Managing Employee |
Dec 31, 2013 | |
| Richard Strait |
Corporate Officer |
Apr 1, 2007 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040219000462 | MD | Part B Supplier - Clinic/Group Practice | 9335057355 |
Receives reassigned benefits from 18 practitioners 2 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Cumberland, MD; Hancock, MD |
| O20051019000147 | MD | Part a Provider - Federally Qualified Health Center (FQHC) | 9335057355 | Practice locations: Cumberland, MD |
National Provider Directory
- Tax ID family
- Tri-State Community Health Center Inc
Locations
621 Kelly Rd
Cumberland, MD 21502
Phone (301) 722-3270
12502 Willowbrook Rd
Ste 550
Cumberland, MD 21502
Phone (301) 723-3940
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
Addresses
Primary practice location
12502 Willowbrook Road
Ste 550, 5TH FLR.
Cumberland, MD 21502-6393
Mailing address
109 Rayloc Dr
Hancock, MD 21750-1518
Phone (301) 678-5187
Other names
- Tri-State Women's Health Center
Other providers in Cumberland, MD
- Transitioncare LLC
- Sheila Tranum
- Cecilia Ann Trent
- Tri-State Community Health Center-Hosp Physicians Practice
- Tri-State Community Health Center, Inc
- Tri-State Community Health Center, Inc
- Tri-State Radiology, PC
- Trio Medical Solutions LLC
- Tristate Hand and Occupational Therapy Inc
- Tristate Home Medical, L.L.C.
All providers in Cumberland, MD · Federally Qualified Health Center (FQHC) in Maryland
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on May 6, 2010. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.